Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Sunday, April 06, 2008

Apropos of prior posts, I feel the NEED to highlight for the readers what, in my mind, is the doucheiest of doucheitude in medicine: JCAHO and Press-Ganey.

We've talked about these gorillas (see cartoon) in the past, but for you new readers, let me briefly introduce you:

JCAHO, (which, for some reason, is pronounced "Jay-Co", not "Ja-Ca-Ho"), also alternatively called, unironically, by the self-designated Orwellian moniker, "The Joint Commission", is a clusterfuck group that "accredits" hospitals by coming in for about one day a year and making sure a bunch of forms have been properly filled out. They have introduced to the medical lexicon gems such as "sentinel events", "core measures" and, the "do not use" list of abbreviations. I went to their web site to see if I could dig up some bullshit and it took me, oh, seconds to navigate all the way to the home page to find the first of many sucktasticisms: They are announcing the Speak Up! program to help patients understand docs better. Each letter in "speak up", of course, stands for something (these turd farmers love the acronyms). And we get to the "U":

"Speak Up™ urges patients to:Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by The Joint Commission."

Hmmmm. Self-serving? Annoying? Chock-full-o-'business-speak'? Oh yeah. If they were just merely useless that would be OK, but these fucksticks have literally changed the practice of medicine by putting up continuous blockades to the delivery of care: fill out yet another form; 'accredit' yourself to wipe shit on a card and see if it changes color; answer to clipboard carrying nurses if you don't fulfil your core measures; and on and on...

Now, Press-Ganey. This is a survey company that asks patients to respond to questions about the quality of care they received. Really it is the PERCEIVED quality of care measured, often from non-paying "customers", who demand perfection and know very little about medicine (a hospital, by the way, is not a hotel. Sorry.) A 'mean nurse' can fuck your Press-Ganey scores relative to other hospitals. A doc who will say "no, I know better" to the annoying patient will drop you to the bottom of the list.

I learned about these a-holes when a rep from the company came to present their survey findings to the hospital. First, he introduced his company by mentioning that it was founded by "Doctors Press and Ganey". I looked up "doctors" Press and Ganey and they, in fact,are not real doctors but PhDs in statistics and cultural anthropology. Nice to be lied to right out of the box. Anyway, I shit you not when I say I was in awe of the audacity of the rep, standing in front of a group of doctors and making the following statement (one of many winners): "Patient privacy is important. On your survey patients said the privacy in the ER was lacking. Let me tell you how you can fix this for NOTHING! When you pull the curtain to separate the beds, say 'I'm doing this for your privacy', and your scores will, I guarantee, improve!" In other words: privacy is a problem; instead of ACTUALLY making the ER more private, PRETEND that it is more private and the PERCEPTION will improve. Fix perception, not the actual problem. Great recommendation, Jackoff. This is the essence of Press-Ganey.

This is but a brief introduction to the people who now dictate how medicine is practiced. Control has been handed to the paper pushers and taken away from the doers. I weep for our profession.

I like how everyone knows exactly when JCAHO is coming, like its a friggin Olympics or something. The commission that inspects residency programs is similar. The Attendings call room became the residents for the few days they were there, not because it was any nicer, they just didn't want the inspectors to see our confederate flags or whatever else they thought we had.

e^(i*pi), thanks for verbalizing the shifty similarities between THE JOINT COMMISSION & Orwell. It really is something people have to see to believe, all ubiquitous posters admonishing everyone to "Be Ready For JCAHO!" If I don't view the mandatory 15 minute flash video on the elegant beauty of hand washing, I know that they'll know. And if they know, they'll find me lacking, and it's a 3am knock on the door, and the next day there's some suit from the Ministry of Truth airbrushing another disloyal prole from the lab roster.

This whole JCAHO thing seems to be getting seedier by the year. I DID COMPLETE my handwashing lovefest video, and hark, what is the most effective method for cleansing the filthy phalanges? JCAHO has the answer- it's the new hand sanitizing foam that was just installed in three inch increments along the hallways! Now lets see, JCAHO makes a "recommendation," and the hospital buys a truckload of these handfoam things. What the hell happened to soap? Create artificial, seemingly "progressive and innovative" but ultimately unnecessary needs that can be met relatively easily and at a "not insignificant" profit, and you've got yourself a hell of a self sustaining system. Those Himalayan piles of forms cost money, and someone has to make them. "Who's paying?" would be my next question. I think there are probably more dirty deals going on here than backstage at a George Michael concert, but hey, WTF do I know?

But don't use the hand sanitizer. You must wash your hands. But also use the hand sanitizer. VRE won't be stopped by hand sanitizer. But use hand sanitizer. And slap up some "Stopping MRSA is in your hands!" posters on every motherfucking 3" square surface surrounding sinks. And wash your hands. And use hand sanitizer. And don't use hand sanitizer. And wash your hands.

That's to say nothing about neck ties. Fucking neck ties probably spread more MRSA than and dirty hand ever did. You ever see someone wash a neck tie? Filthy. And who wears neckties? JCAHO. Spreaders of death a gloom.

I remember JACHO and CLIA when I worked in a hosptial lab. It sucked, but I was anal enough to do everything. We did have a couple hardened old chicks who worked the day shift who refused to do anything that JAHCO demanded. We got a very nasty letter from them in the end, so we basically failed.

It was actually kind of funny. Although I was shocked and horrified at the time because I wanted the lab to get a pass. I was always actually more horrified by the lab techs who would get serum on their gloveless hands and then just wipe it off.

Dr. Feelgood, Give me a break--MDs are not just a technical degree any more than I'm a real doctor (juris doctor). It's just annoying when Phds and Edds call themselves "doctors". You have a respected academic degree that you worked hard for--an academic doctorate. I have a professional degree that nobody, including me, respects, and Etotheipi is is a real doctor. When you're on a plane and have a heart attack, they aren't asking for you or me when they ask if there's a doctor on the plane.

doctor feelgood: you must be a PhD to actually think PhDs have any worth in this life or the hereafter. And thanks for the info that an MD is an UNDERGRADUATE degree. That's odd because I spent four fucking years learning some liberal arts jerkwad crap, then 4 in a POSTGRADUATE medical program then 5 years in residency so I can diagnose fucking PhD doucheholes with ass-cancer. Eat my scrotum. Out.

One of the surgery residents at my school hadn't graduated from highschool or college. He was a braniac who went to college early and then when he got accepted to medical school figured why waste the tuition for another semester. And yeah, the state was Mississippi. The Pre-med advisor at my college was a PhD from England. He insisted on being called "Mister" rather than "Doctor".

Exactly. Here in CA I had a philosophy prof from Columbia, and he always said the better the university, the less likely that the profs want to be called "Dr." He insisted we call him "Jerry", but then he also slept with his students.

I am a software engineer, and I've been writing code for computers for 30 years now.

Software is a complex system, and complex systems are... complex!

The entire medical system is also a complex system. One given hospital is a complex system. Each person within that hospital is a complex system as well, and their medical situation is pretty darned complex.

So, what do us engineers know about complex systems?

You CAN NOT TEST QUALITY INTO YOUR SYSTEM.

Testing (forms, etc, all that crap you guys have) can not create quality. What a test (form) can DO, however, is provide feedback that can then be used to change the system, little by little, until things are (hopefully) better.

But you have to have the RIGHT test, and then you have to have the right RESPONSE to the test.

The test must address the core function of the system. Is a hospital there to "make patients happy" (easy, unlock the morphine cabinet!) or to "make patients well"? If you are testing patient happiness, how does this help you improve the system to make patients well?

Also, you have to ask of each system represented -- what is their "success" defined as? To Press-Ganey, "success" is doubtless defined as "having more hospitals hire us" and not "making hospitals better".

All this junk y'all blog about is about the marketing of the hospital, for the suits and ties up there in management who want a shiny face for the community. It sounds like they have lost track of the real purpose of their institution.

I once was an EMT, several life-changes ago. Since then, I'm just a well-informed patient.

In my post-TKA rehab stay a few weeks back I lambasted an RN for allowing her DISGUSTING smock to brush against my incision when she was changing dressings. I demanded the necessary materials and scrubbed myself with povidone/iodone pads and thereafter changed my own dressings.

Same nurse, after her thermometer malfunctioned, removed it from my mouth then used her bare hand to properly seat the plastic thermometer cover. She got shiatty with me when I refused to allow her to put it back in my mouth.

To top it all, when I insisted on a fresh one, she pulled the old one off -- again with her bare hand. I tried to politely explain: "Look -- you just touched the dirty one. Odds are you did the same for the sick LOL down the hall. I'm sure they taught you about microbe-transmission in nursing school -- NO?"

She never came to take my "vitals" again -- for all I know she simply falsified the records, copying what the shifts before had written...

As to the press-ganey thing, I got one of those in the mail. I tossed it in the trash, which is where such things belong.

I have some serious concerns about the quality of the care I was given, and I fully -- FULLY -- intend to address them with the hospital when I am back on my feet, but I will be DAMNED if I am going to allow some stupid "check yes or no..." questionaire to do my speaking for me.

The problems I had were with specific people, and I am going to name names, not tar the good with the brush deserved by the bad.

This trailer-park-princess nurse also had cheap jewelry on every finger. Ever notice the crud that builds up in the cracks and hollow-backs of cheap rings? There's not enough scrub in the country to make her hands sanitary with those disease-tanks on them...

I always fill out he stupid forms and return them because I don't want the data to be driven only by malingerers, litigious malcontents and home-bound hypochondriacs. I feel bad for my doctors, being subjected to the things.

Dad, you really shouldn't piss off the people who prepare your food. OK, the smock was probably nasty, like basically everything that hasn't been autoclaved, but who are you, the bubble boy? I'm with you on the thermometer and jewelry thing, hell I put on gloves even for phone calls. Howard Hughes was a disgusting slob compared to me. And the Vitals? no one ever looks at them except in court, and its bad if they're abnormal, so theres alot of 110/60,72,12,98.8s out there. If you can't tell someones sick without looking, probably not gonna notice from a buffed vital sign.

Frank Drackman-Thank you! I have been trying to remember Howard Hughes' name for MONTHS because of something my husband and I were talking about. I used him as a point in something I was saying but since I am horrible at remembering names, I could not think of his name and my point was meaningless. Because of this, my husband won the argument/discussion that I can't even remember what it was about, but I have been trying to remember the guy's name since then. Perhaps I have a touch of the obsessive part of the OCD that he had?

We had a douchey trend in our ER. Mr. Schmooze, the same doctor that gets paid $100,000/year to make the physician's schedule, was informed that EMS personnel did not like how we interacted with them. He started introducing himself saying "Hi, I'm Dr. Schmooze and I've been here 20 years. Thank you for bringing us the patient." He went on and on and talked up the medics. Meanwhile, I'm standing there tapping my toes waiting to get report and taking vitals. Hey, get the hell out of the room and let me take the patient's clothes off and slap them on the monitor and--oh--let's hear about why they're there?

Apparently some "consultant" told us to introduce ourselves and mention something about our experience so that people felt like they were leaving the patient in a good place. Whatever. Get out of the room.

Your Welcome radioactive girl, Hughes was always a hero of mine, flys around the world, dates starlets, and lives secluded, just what I'd do if I was a billionaire.And Nurse K, for awhile in anesthesia residency we were encouraged to introduce ourselves sort of like waiters.."Hi I'm Frank, and I'll be putting you to sleep today. Could I interest you in a nice Isoflurane, 92' or would you prefer the nitrous?" after a few weeks of sounding like a Ruby Tuesdays things went back to normal.

I filled one of these out the other day. I'd had a nerve conduction test on my feet - simple procedure, not much to fear, possible outcomewise, in, out, done.In honor of you, and the joy you bring, and to reflect the lack of irritation involved at the hospital, I gave them the best possible score. Karma widening the Bell Curve, for someone.

I work for Press Ganey and am constantly horrified by the treatment of our clients. In particular, taking 23-25 year old college grads, placing them in customer service rolls and passing them off as "healthcare consultants". Over 70% of these folks have never set foot inside a hospital, been on rounds with a nurse manager, have a clue as to what daily huddles are, or have any healthcare back ground what so ever. It gets better. One of these so called consultants will be speaking this year at the National Client Conference. In fact, this individual is considered to be at the highest level of consulting available to hospitals from Press Ganey. What credentials? This time last year, this individual was working at the mall. Amazing what one can learn in 365 days. Press Ganey will continue to use statistics and its overpriced system to hold healthcare hostage. Ask your "consultant" exactly how much this company earned off its mailing process. Here is a hint, it was in excess of $90 million! Now they want to change in excess of $1 million an engagement to fix the flow in your ORs. How? Blocked schedules! Now that is a million dollar idea. All vendors provide data and it is nothing more than a commodity product. My advice? Find a less expensive vendor and use the cost savings to work on real improvement.

From one Anoymous to another(3.37, June 1)That is the best idea I have heard- doctors starting their own rating agency. Now who is going to bell the cat? What about you 911DOC, now that you are " working" for the gubmint, and have weekends and evenings, and afternoons off?

Wow ! Love this site. Been a psych nurse for 25 years now and find myself more angered and bummed out than ever before. Why ? Idiots (out of touch admins) letting idiots run health care. Entitled borderlines etc are being allowed…..make that encouraged, to drive the art. It’s a trap as the pay is good but my soul is being sucked out of my body. I do take some pleasure in knowing that there are others who get it.